Provider Demographics
NPI:1225146657
Name:MIDWEST PHYSICAL MEDICINE AND REHABILITATION PLLC
Entity Type:Organization
Organization Name:MIDWEST PHYSICAL MEDICINE AND REHABILITATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-542-1970
Mailing Address - Street 1:PO BOX 285
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-0285
Mailing Address - Country:US
Mailing Address - Phone:734-542-1970
Mailing Address - Fax:248-614-9756
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 314
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-542-1970
Practice Address - Fax:248-614-9756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076422208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P37730Medicare PIN
MI0P37720Medicare PIN
I08446Medicare UPIN
MI0P37720Medicare PIN